A second-generation iStent, approved last summer, is approximately 0.23 millimeters times 0.36 millimeters.

Another type of MIGS device, the XEN gel stent, creates a new channel to reduce pressure by shunting fluid to the outside of the eye. It’s 6 millimeters long and the width of a human hair.

Two local ophthalmologists interviewed, each of whom has fellowship training in glaucoma, were enthusiastic about MIGS and pleased with glaucoma medicines introduced within the past 18 months.

“We’re undergoing a revolution in the way glaucoma care is delivered, not only surgically but with medication,” said Dr. Alexei L. Moraczewski of Advanced Eye Care Associates.

Fortuitously, these advances come as the steady tide of aging baby boomers increases the number of patients with eye problems. They’re able to choose from options their parents didn’t have.

“The technology and the treatment have come such a long way,’ said Dr. Aly Sheraly, who is with Eye Specialists of Mid-Florida.

Traditional methods vs. MIGS

The concept of draining fluid from the eye through devices isn’t new.

Using small silicone tubes to improve drainage is an often-used procedure to lower pressure.

These traditional stents paved the way for MIGS, but “have a higher complication rate than we’d like sometimes,” Moraczewski said.

Trabeculectomy, traditional surgery, is a gold standard of glaucoma care when medical or laser treatments don’t lower pressure enough. The eye surgeon creates a new path through which the eye can release excess fluid.

Both procedures are safe and effective in many patients.

But, since complications do occur, ophthalmologists often hesitate to recommend those traditional eye surgeries for patients with mild to moderate glaucoma unless other treatments aren’t successful.

MIGS, however, is for patients with mild-to-moderate, open-angle glaucoma. It seems likely to be recommended more quickly.

“MIGS allowed us to do surgery in a more safe, controlled manner,” Sheraly said. “It’s allowed us to make smaller incisions and allowed for faster recovery.”

Many eye surgeons, not just glaucoma specialists, are exploring the variety of MIGS devices available. The February edition of Ophthalmology Management focuses on the explosion of MIGS, new medicines and diagnostic equipment.

But what about eye drops?

Prescription eye drops continue to be the first line of treatment for the vast majority of glaucoma patients.

Optometrists have a role in diagnosing many glaucoma cases and can treat patients with eye drops, although surgical procedures are left to ophthalmologists like Sheraly and Moraczewski.

The two new medications are Vyzulta (latanoprostene bunod ophthalmic solution) and Rhopressa (netarsudil ophthalmic solution). They’re believed to work on a spongy layer in the eye called the trabecular meshwork, part of the trabecular pathway, a major part of the eye’s natural drainage system.

These newer medicines can be given in addition to a patient’s current eye drops or as first-line treatment.

“We’re still trying to figure out their place in our patient’s treatment plan,” Sheraly said.

Vyzulta breaks into two separate molecules, one of which releases nitric oxide. Nitric oxide is believed to relax tissues to let more excess fluid drain out, Sheraly said.

The other molecule in Vyzulta is latanoprost, an existing, commonly used medication.

Rhopressa inhibits an enzyme called ROCK (rho kinase), letting more fluid be removed through the trabecular meshwork, Moraczewski said. It also may decrease fluid production in the eye.

If patients are happy with their existing eye drops, and doing well on them, they don’t need to change.

Some patients do well permanently on one or two glaucoma medications.

Others don’t. They report side effects like stinging in the eyes, have difficulty getting the drops in their eyes or forget to take them.

“One of the main reasons people lose vision from glaucoma is they don’t take their medication or don’t follow up (to make sure it’s brought their pressure down enough),” Moraczewski said.

Another is that they don’t get eye examinations in time to detect the glaucoma before damage occurs. Glaucoma doesn’t have early symptoms.

If eye drops aren’t effective or people have trouble taking them, two laser treatments — selective laser trabeculoplasty and argon laser trabeculoplasty — are another alternative to help open the eyes’ natural drainage system, according to the Glaucoma Research Foundation.

Patients and their eye doctors can consider those older procedures in addition to the newer option of MIGS.

Robin Williams Adams can be reached at robinwadams99@yahoo.com.

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